Healthcare Provider Details

I. General information

NPI: 1972744654
Provider Name (Legal Business Name): DIANE DECILLIS JOHNSTON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2009
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 BRADBURY DR SE STE 2222
ALBUQUERQUE NM
87106-4375
US

IV. Provider business mailing address

675 TOWER AVE SUITE 301
HARTFORD CT
06112-1273
US

V. Phone/Fax

Practice location:
  • Phone: 505-365-2146
  • Fax:
Mailing address:
  • Phone: 860-714-2750
  • Fax: 860-714-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP54774
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: